Atlantoaxial Rotatory Fixation Research Articles

Article Commentary: “Spontaneous Ankylosis of Occiput to C2 following Closed Traction and Halo Treatment of Atlantoaxial Rotary Fixation”

The authors present a unique case of an 11-year-old child with spontaneous fusion of his occiput to C1–C2 following traction, manipulative reduction, and halo immobilization for refractory atlantoaxial rotatory fixation. The child initially presented with torticollis, neck pain, and headaches and underwent numerous chiropractor manipulations over 9 months with alleviation of his neck pain and headaches. However, his torticollis persisted; thus, he was referred to an orthopedic surgeon where initial workup included magnetic resonance imaging, magnetic resonance angiography, and computed tomography (CT) imaging. This revealed a Fielding and Hawkins type II rotatory fixation, with remodeling changes involving the left C2 articular facet. The treatment options of surgical versus nonsurgical reduction were discussed with the family, and they decided for nonsurgical reduction and immobilization. Thus, the child was placed in traction and had improvement but not complete resolution of his rotational deformity. Subsequently, an attempt was made to preserve the traction reduction with halo vest immobilization for 3 months. At his 6-month follow-up, the patient demonstrated mild residual torticollis. CT imaging was obtained to provide further clarity on bony anatomy and showed spontaneous fusion from the occiput to C2. Because most of the head and neck rotation occurs at the occiput–C1–C2 integrated functional complex, it is desirable to try to preserve the motion levels around the craniocervical junction as much as possible. Therefore, nonsurgical management is the clearly recommended first line of treatment using halter-type traction and reduction followed by Minerva or halo bracing for 3 months. However, if reduction is not achieved and/or there is persistent atlantoaxial rotatory fixation after 3 months of bracing, surgical reduction and internal fixation fusion for management is the recommended treatment with the hope of limiting the surgical reduction and fusion efforts to the C1–C2 segments. In a retrospective case review, we found instability patterns following nonoperative care of very young children with ligamentous injuries involving the craniocervical junction to be unpredictable with spontaneous ossification not a regular occurrence.1 I agree with the authors' management of this child and would have recommended a similar approach even with the child's very delayed presentation.2 I suspect that the child had extension of his fusion from occiput to the atlantoaxial motion segments secondary to the recurrent trauma of the craniocervical articular surfaces and surrounding soft tissues over the course of numerous chiropractor neck manipulations and/or prolonged traction periods, which eventually led to focal joint inflammation and subsequent spontaneous fusion. Based on our previous surgical experience in operating on the craniocervical junction of the very young patient, surgical reduction and fusion targeting the atlantoaxial segment would not have predictably prevented extension of the fusion to the occipitocranial junction. However, with the advent of innovative magnetic resonance imaging, one may be able to predict who will have extension of the fusion by highlighting increased signal of the occiput–C1–C2 complex ligaments. For example, Landi et al found increased signal in the alar, capsular, and transverse ligaments in two patients with Fielding and Hawkins type II rotatory fixation using short T1 inversion recovery (STIR) sequences.3 Overall, the management of refractory atlantoaxial rotatory fixation in children remains challenging and frustrating. The one remedy in absence of a decisive evidence-based treatment is to clearly present all treatment options to the patient and their family to invite a shared decision-making approach for outcomes like the occurrence of a spontaneous fusion.

Atlantoaxial rotatory fixation followed by atlantoaxial subluxation in a child with Down’s syndrome : A case successfully treated with atlanto-axial fixation

Atlantoaxial rotatory fixation followed by atlantoaxial subluxation in a child with Down’s syndrome : A case successfully treated with atlanto-axial fixation

One case of atlanto-axial rotatory fixation treated by closed reduction under general anesthesia

One case of atlanto-axial rotatory fixation treated by closed reduction under general anesthesia

Efficacy of Nonfusion Treatment for Subacute and Chronic Atlanto-Axial Rotatory Fixation in Children

Historical guidelines suggest limited efficacy for nonfusion treatment of chronic atlanto-axial rotatory subluxation/fixation (AARF). Surgical fusion has potential side effects; therefore, it is important to understand the role for nonfusion treatment of chronic AARF. This case series examines the success rate of nonfusion treatment. A key word search was used to identify all patients with AARF with delayed presentation of ≥ 4 weeks. Fifteen patients met study inclusion criteria and had adequate clinical information for review. Data collected included age, sex, delay in presentation, mechanism of injury, severity of subluxation (Fielding classification), treatment, follow-up, and clinical information at latest follow-up. There were 11 girls and 3 boys with an average age of 7.2 years (range, 1.5 to 12 years). Initial treatment of 3 patients included fusion. Eleven patients were initially treated without fusion. Eight of these 11 patients were successfully reduced with either halter traction, halo gravity traction, and noninvasive halo or halo vest, and reduction was maintained without fusion (73%) at 10.3 years follow-up. Three patients (27%) experienced recurrence of AARF at an average time of 2 weeks (range, 0 to 4 wk) and were treated with fusion. Average delay in presentation for all patients was 18 weeks (range, 4 to 92 wk), whereas it was 6 weeks and 9.3 weeks in those successfully treated without fusion and in those who failed nonfusion treatment, respectively. Age, delay in presentation, and underlying diagnosis were similar for fusion and nonfusion groups. Although AARF may recur after a trial of reduction and nonfusion treatment, pediatric patients with delayed presentation (>1 month) of AARF may be treated with an initial trial of nonfusion treatment. Parents should be counseled about the risk of recurrence and possible need for ultimate fusion. Level III, therapeutic retrospective comparative study.

Adult Traumatic Atlantoaxial Rotatory Fixation: A Case Report

We presented a very rare case of adult Fielding type I atlantoaxial rotatory fixation (AARF). We performed awake manual reduction of the dislocation without need for anesthesia, achieving excellent outcomes, and no previous reports have described awake reduction without the need for anesthesia. AARF in this case was attributed to excessive extension and rotation forces applied to the cervical spine. For the management of adult Fielding type I AARF, early diagnosis and early reduction may lead to excellent outcomes.

Traumatic atlantoaxial rotatory fixation associated with C2 articular facet fracture in adult patient: Case report

Traumatic atlantoaxial rotatory fixation is a very rare injury in adults which is often misdiagnosed initially. Its combination with C2 fractures is predominated by dens lesions. Therapeutic management is challenging because of the difficulty to achieve optimal reduction and permanent stability. We report a rare case of traumatic atlantoaxial rotatory fixation in a 56-year-old women associated with C2 articular facet fracture successfully treated by conservative means after patient-awake manual reduction with optimal functional and radiographic outcome.

A successful case report of chronic atlanto-axial rotatory fixation with conservative treatment

A successful case report of chronic atlanto-axial rotatory fixation with conservative treatment

Condylus tertius with atlanto-axial rotatory fixation: an unreported association

The "condylus tertius" or the "third occipital condyle" is an embryological remnant of the proatlas sclerotome. Anatomically, it is attached to the basion and often articulates with the anterior arch of the atlas and the odontoid apex; hence, it is also called the "median occipital condyle". It is a rare anomaly of the cranio-vertebral junction (CVJ) that can lead to instability and compression of important surrounding neurovascular structures. We report a case of a 16-year-old boy who presented with suboccipital neck pain, torticollis and right sided hemiparesis. Plain radiographs revealed an increased atlanto-dental interspace (ADI) with a retroflexed odontoid. Open mouth view showed asymmetry of the articular processes of the atlas with respect to the dens. Computed tomography (CT) of the CVJ delineated the third occipital condyle. Furthermore, on dynamic CT study, a type 3 atlanto-axial rotatory fixation (AARF) was clearly demonstrated. Magnetic resonance imaging (MRI) of the CVJ revealed severe right-sided spinal cord compression by the retroflexed and rightward deviated dens. It also revealed disruption of the left alar and transverse ligaments. The patient was treated with 8 weeks of cranial traction and reasonable alignment was obtained. This was followed by C1-C2 lateral mass screw fixation and C1-C2 interlaminar wiring to maintain the alignment. A review of the literature did not reveal any cases of condylus tertius associated with non-traumatic AARF. An accurate knowledge of the embryology and imaging features of this rare CVJ anomaly is useful in the prompt diagnosis and management of such patients.

Surgical treatment for chronic atlantoaxial rotatory fixation in children

Six consecutive pediatric patients with chronic atlantoaxial rotatory fixation (AARF) underwent posterior fixation. All patients were first treated conservatively such as with a neck collar, traction, Minerva jacket, or halo-vest; however, they failed to achieve successful reduction because of the C2 facet deformity or C1-2 facet fusion. We performed C1-2 fusion using a C1 lateral mass screw and a C2 pedicle screw, a C1-2 transarticular screw, or an occipitocervical fusion using a rod and wiring system. Five patients achieved solid fusion with no torticollis or neck pain by the final follow-up. One patient had mild torticollis after surgery but no pain. Although we believe that with early diagnosis of AARF and appropriate conservative treatment we can avoid surgery, even with conservative treatment from the onset of symptoms, five patients in our series required surgery because conservative treatment did not lead to successful reduction. When conservative treatment for chronic AARF patients fails, C1-2 transarticular fixation, and C1 lateral mass screw and C2 pedicle screw fixation are reliable methods to treat these patients.

Early Diagnosis and Management of Combined occipitoatlantoaxial rotatory fixation, Case Report and Review of the Literatures

Background Data: atlantoaxial rotatory fixation (AARF) although rare, is a wellknown condition to most spinal surgeons. Occipitoatlantoaxial rotatory fixation (COAARF) is a condition that may develop as a compensatory event following AARFmaking diagnosis more difficult. Most cases of COAARF present late making their management a difficult task.Purpose: to demonstrate a neglected case of COAARF Study Design: case report Patients and Methods: we report a 9 years old girl with neglected COAARF following minor trauma. 7 months after trauma we could not reduce its rotation operatively. Results: delayed diagnosis of COAARF precluded its reduction Conclusion: COAARF can result from relatively minor trauma and should be suspected in children with persisting neck pain and decreased neck movements.Early diagnosis of COAARF is important and facilitates its management. MS and 3D CT-scan is the corner stone in its diagnosis. (2013ESJ053)

Atlantoaxial rotatory fixation in a child after bilateral otoplastic surgery

Atlantoaxial rotatory fixation (AARF), which is a dislocation or subluxation of the atlantoaxial joint, is a well-recognized condition in children. We present a case of AARF after otoplastic surgery for bilateral cryptotia performed by plastic surgeons. The pediatric patient presented with neck pain and torticollis after the surgery, and an orthopedic surgeon diagnosed AARF. The patient was treated successfully with conservative treatment incorporating mild manual manipulation, neck traction, and a collar for 1.5months. Physicians should consider the possibility of AARF when a patient presents with neck pain and torticollis after otoplastic surgery; diagnosis and treatment should be started immediately.

Effect of Rehabilitation on a Child With Atlantoaxial Rotatory Fixation

Case report. To discuss a case of atlantoaxial rotatory fixation (AARF) successfully treated with manual therapy. A 9-year-old girl experienced acute torticollis and neck stiffness after a traffic accident. Image studies revealed AARF, a cause of pediatric torticollis. She received closed reduction with the aid of C-arm fluoroscopy under general anesthesia. She was referred to the researchers' rehabilitation clinic because of unsolved torticollis and limited head rotation. At her initial visit, we found that her head tilted to the right and rotated to the left. Tenderness and muscle guarding over the right suboccipital region were also apparent. The first manual therapy significantly improved neck motion after soft tissue release applying to the suboccipital muscle group. We arranged for her to enter a rehabilitation program including (1) soft tissue release technique to the suboccipital muscle group for 10 minutes and (2) muscle energy technique for neck flexion, extension, lateral bending, and rotation for 10 to 15 minutes. After 3 months' rehabilitation, her symptoms of torticollis, neck pain, and limited range of motion achieved near-total recovery. This case report presents the association between suboccipital muscles and AARF, suggesting that the soft tissue release of suboccipital muscle group may facilitate recovery from AARF. More studies are needed to verify the inferences of this case report.

A Case of Atlanto-axial Rotatory Fixation Following Cochlear Implantation

We report herein on a 6-year-old girl with atlanto-axial rotatory fixation (AARF) which occurred after cochlear implantation under general anesthesia. The cochlear implantation procedure appeared normal, and took 3 hours and 50 minutes. On the 1st postoperative day, the patient complained of neck and shoulder pain but she could rotate her head. On the 4th postoperative day, she had torticollis without any neurologic damage and neither active nor passive rotation of the head could be achieved. She was diagnosed as having AARF on the basis of the computed tomographic findings. She was treated with Glisson’s traction for 4 days to correct the deformity. AARF is a rare disorder and its diagnosis is often difficult and delayed. CT scans, especially 3-D reconstruction, are useful to diagnose AARF. It is suggested that AARF can occur after a cervical injury or an upper respiratory tract infection. AARF is also occasionally caused after head and neck surgical procedures such as pharyngeal flap plasty, ear surgery, and plastic surgery for microtia. It is important to be aware of the possible occurrence AARF and to start appropriate treatment as soon as possible.

Combined Atlantoaxial Rotatory Fixation and Unilateral Counter Occipitoatlantal Subluxation after Minor Trauma

Rotatory deformities of the atlantoaxial joint may becaused by trauma, upper respiratory tract infection, juvenile rheumatoid arthritis, congenital condition (Down’s syndrome, Marfan’s syndrome). Although most of them are reduced spontaneously or with traction, in rare cases, they may persist. To describe such persistent rotation, Wortzman and Dewar in 1968 used the term, rotary fixation of the atlantoaxial joint. In 1977 Fielding and Hawkins used the term, atlantoaxial rotatory fixation (AARF), because the fixation of the atlas on the axis may occur with subluxation or dislocation. Although AARF in children may be a well-documented, combined AARF and occipitoatlantal subluxation is a rare disease. Patients with combined AARF and occipitoatlantal subluxation has less rotated and tilted head than those with AARF only, because of counter occipitoatlantal subluxation. So it is often difficult to diagnosis accurately. We report a case of combined AARF and unilateral counter occipitoatlantal subluxation after minor trauma. Case Report

Atlantoaksial rotasjonsfiksasjon – en årsak til torticollis

A rare, but important cause of torticollis in children is atlantoaxial rotatory fixation. If the patient remains undiagnosed for more than three months, surgery is generally the only therapeutic alternative. In this article we present our experiences of surgical treatment of late-diagnosed atlantoaxial rotatory fixation in children. This article is based on a review of the case notes of patients who underwent surgery for atlantoaxial rotatory fixation in the Department for Neurosurgery at Oslo University Hospital, Rikshospitalet, during the period 2004-10. The material sample consists of six children aged from seven to 14 years. Five had suffered minor trauma to the upper neck region, while one had had an upper respiratory tract infection. The diagnosis was made 5-36 months after the onset of symptoms. In three of the patients, an attempt was made at closed reduction without success. A CT scan one year postoperatively showed a normal position of the atlantoaxial joint in two patients and partial reduction in three. In the sixth patient there was bone fusion at the time of the operation, and open reduction was unsuccessful. All six patients had reduced rotational movement of the neck at the one-year check-up. All our patients were diagnosed more than five months after the onset of symptoms. Full or partial reduction was achieved in five of the six.

Atlantoaxial transarticular screw fixation: a technique never reported from (sub-saharan) Africa?

Background: Atlantoaxial transarticular screw fixation is considered to be the gold standard for treating atlantoaxial instabilities. This challenging surgical procedure requires high skills and appropriate surgical armamentarium. Such conditions are rarely met in sub-Saharan Africa. After a thorough review of medical literature, we did not find a single report on atlantoaxial transarticular screwing from Africa. For this reason, we decided to report on a case we operated on at our institution. Methods: We retrospectively reviewed a case of post-traumatic acute atlantoaxial rotatory fixation (AARF) associated with C5-C6 left facet joint dislocation that we managed in our hospital with posterior atlantoaxial/transarticular screw fixation and C5-C6 lateral masses plating. Results: A 56 years old female was admitted to our service for head and cervical spine trauma following a road traffic accident. She had asymmetrical quadriplegia and urinary retention. Computed tomography (CT) scans revealed a type II atlantoaxial rotatory fixation of left atlantoaxial joint along with stage II distractive-flexion injury of left C5-C6 facet joint. Transcranial traction with Gardner-Wells tongs was performed and patient subsequently underwent surgical stabilization with modified Magerl's technique and C5-C6 lateral masses plating. Fourthy-five days after surgery, the patient was able to walk alone without any help.

Relationship between the Atlantoaxial rotatory fixation and the Lifestyle Case study of four Elementary school children

Relationship between the Atlantoaxial rotatory fixation and the Lifestyle Case study of four Elementary school children

Grisel's syndrome: An unusual cause of Torticollis

The objective of this paper is to present a case series of patients with diagnosis of torticollis due to Grisel's syndrome and, in doing so, raise awareness of an unusual condition that could be fatal. A review of the literature is presented regarding diagnosis and treatment. Case series of three patients that were 7, 10, and 12 years old with history of tonsillitis or neck surgery consulted to the service of Rehabilitation Medicine. Physical examination showed a fixed head or limitation of movement to neutral position and initially a normal neurological examination. Initial cervical X-rays were not diagnostic. The final diagnosis was made by CT scan or MRI. All 3 patients were treated with anti-inflammatory medications, immobilization, and/or cervical traction or surgery. Grisel's syndrome is a non-traumatic atlanto-axial rotatory fixation (AARF) with or without subluxation following infection or surgery in the head or neck region. This paper presents an unusual cause of torticollis that could be fatal or cause neurological injury if not recognized and treated appropriately.

A case report atlantoaxial rotatory fixation with bony anomaly on upper cervical spine

A case report atlantoaxial rotatory fixation with bony anomaly on upper cervical spine

Posterior occipito-axial fixation applied C2 laminar screws for pediatric atlantoaxial instability caused by Down syndrome: Report of 2 cases

BackgroundUpper cervical spine instability is one of the most critical orthopedic problems in patients with Down syndrome. However, arthrodesis of the upper cervical spine in these patients can be very difficult to achieve and has a high complication rate because of mental retardation and accompanying various medical conditions of the vital organs. Even now, surgeries in such patients, especially pediatric cases, are challenging and the optimal operative procedure remains unsettled. The purpose of this study was to report 2 cases of pediatric atlantoaxial instability due to Down syndrome in which posterior occipito-axial fixation with C2 laminar screws was performed. MethodsCase 1 was a girl aged 6 years 10 months who had atlantoaxial rotatory fixation with os odontoideum. Atlantoaxial rotatory fixation was incompletely reduced by halo traction, and it was not maintained without halo-ring and -vest fixation. Posterior occipito-axial fixation with bilateral C2 laminar screws was then performed. Case 2 was a boy aged 10 years 7 months who had atlantoaxial subluxation with os odontoideum. He also had incomplete quadriplegia, so he could neither walk nor have a meal by himself. Posterior occipito-axial fixation with right C2 pedicle and left C2 laminar screws was then carried out. ResultsIn case 1 bone union was obtained at 3 months after surgery and the patient's symptoms were resolved. In case 2 bone union was obtained at 3 months after surgery and the paralysis was improved. Conclusions/level of evidenceIn cases of atlantoaxial instability due to Down syndrome, symptomatic patients often present between ages 5 and 15 years and mental retardation interferes with postoperative cervical immobilization. C2 laminar screws can be safely applied for the pediatric axis and biomechanically accomplished rigid fixation. The C2 laminar screw is one of the most useful options to achieve stability of the pediatric atlantoaxial complex without the risk of vertebral artery injuries (level IV case series).